Dr. Jeff Hersh: Severe morning sickness may require hospitalization

Q: I had morning sickness when I was pregnant, but my best friend has it so badly that she has needed to go to the emergency room multiple times. Is this normal?

A: Nausea and even some vomiting during pregnancy, colloquially referred to as “morning sickness” (although this is clearly a misnomer as it may affect women at any time during the day, and even to some extent throughout the entire day) is extremely common, affecting over 80 percent of pregnant women. Although these symptoms typically start around 5 to 10 weeks gestation, peak around 11 to 13 weeks gestation and usually resolve by around 12 to 16 weeks gestation, for up to 10 percent of women, symptoms continue through week 26 and even up to the time they deliver. Some researchers have conjectured that mild nausea/vomiting during pregnancy may be protective of the fetus, possibly by making mom more sensitive to potentially toxic foods/ingestions; women with “morning sickness” may have a lower incidence of miscarriage and stillbirth.For about 0.3 percent to 2 percent of all pregnant women, the nausea and vomiting are severe enough to cause weight loss, volume depletion (colloquially called dehydration), imbalance of blood electrolytes and/or nutritional deficiency; this condition is called hyperemesis gravidarum (HG).

The cause of HG is not really understood, although there are many theories:

* There may be a genetic component as the condition is more common in women whose mother suffered from it.

* The similarity of the symptoms to motion sickness have made some researchers suspicious that at least some cases are due to an “uncovering” of underlying vestibular disorders.

* Some women start to feel nauseous even from the smell of food, and so increased olfactory sensitivity may be a contributing factor.

* Hormonal factors likely play a role. There is evidence of increased thyroid gland activity in over half of women with HG. Increased levels of other hormones (for example hCG) may also play a role.

* Abnormal stomach emptying and/or digestive system contractions are common in women with HG, as is the presence of at least some amount of gastroesophageal reflux disease (GERD) and even helicobacter pylori (a bacterial colonization in the stomach associated with ulcers). So gastrointestinal changes with pregnancy likely contribute to HG.

* Whether as a cause or effect (not clear which), liver function is often at least mildly abnormal in most patients with HG.

* Psychological factors (such as a pronounced reaction to the increased stresses associated with pregnancy) may also play a role, although once again whether this is a cause or effect of the HG is not really known.

The diagnosis of HG is based on the severity of symptoms and the consequences of these symptoms (as above), and may be supported by findings on the physical exam demonstrating volume depletion (rapid heartbeat, low blood pressure and/or other signs of “dehydration”). When HG is suspected, blood tests to check electrolytes, liver function, thyroid function and even pancreas function may be indicated. A urine test will be done to help evaluate the patient’s fluid status as well as to look for a possible urine infection (which could exacerbate the symptoms). Although imaging is not needed to diagnose HG, an ultrasound may be done to verify how far along the pregnancy is, to determine whether it is a single fetus or multiple and in some cases to evaluate abdominal organs to rule out other diseases.

Morning sickness is usually adequately treated with reassurance, avoidance of symptom triggers and careful oral fluid replenishment (small amounts taken frequently). Acupuncture and/or acupressure have been shown to be helpful in many women to alleviate symptoms. Supplementation with pyridoxine (vitamin B6) is often beneficial.

In severe cases (such as HG), anti-nausea medications, whether herbal medicines (such as ginger), over-the-counter medicines or prescription medications, may be required (remember that during pregnancy, all medications are to be used only if needed and under a healthcare provider’s direction). For women who are volume depleted or who have electrolyte imbalance, intravenous (IV) fluid therapy may be needed. In very severe HG cases hospital admission for ongoing fluid replacement and symptomatic therapy may be indicated.

Although morning sickness is so common that it can be considered a normal part of pregnancy, HG is not. So women with severe symptoms should see a healthcare provider to be sure they receive the best care for them and to ensure a good outcome of their pregnancy.